Transcript
North Carolina Guardianship Association Post Office Box 17673 Phone: (919) 266-9204
Raleigh, North Carolina 27619 Fax: (919) 266-9207
Email:
[email protected]
Website: nc-guardian.org
APPLICATION FOR CERTIFIED GUARDIAN (Must be completed and notarized)
1. Full Name: ___________________________________________________________________________ (As you wish it to appear on your certificate) 2. Are you a member of the North Carolina Guardianship Association?
Yes _________
No _________
3. Business/Agency Name (if applicable): ____________________________________________________ 4. Mailing Address: ______________________________________________________________________ City: ______________________ State: ______ Zip Code: ___________ County:___________________ 5. Daytime Telephone Number: ________________________ Fax Number: _________________________ 6. Evening Telephone Number: ________________________ E-mail Address: ______________________ 7. Education: High School Diploma (or GED) ___________________________ Year Awarded _________________ High School or Certifying Body: ___________________________ City/State ____________________ College/University Degree: _______________________________ Year Awarded ___________________ College/University _________________________________________ City/State___________________ College/University Graduate Degree ________________________ Year Awarded _________________ College/University _____________________________________ City/State_______________________ 8. List your experience providing guardianship or other related work experience, beginning with the most recent: Employer Name/Address ______________________________________ _____________________________________ ______________________________________ ______________________________________
Position __________________________ __________________________ __________________________ __________________________
Start and End Dates ________________ ________________ ________________ ________________
List volunteer experience:___________________________________________________________________ ________________________________________________________________________________________ List experience serving family member or friend with special needs:__________________________________ _________________________________________________________________________________________ Additional comments/clarification __________________________________________________________ ______________________________________________________________________________________ 9. Guardianship Education and Related Courses (Please attach a listing of dates, courses taken, course sponsors, locations and the number of hours completed for each course within the last two years with appropriate documentation.) An Affiliate of the National Guardianship Association
-2-
10. Are you currently serving as a court appointed guardian? If yes, please attach a copy of your Letters of Appointment. 11. If you are a court appointed Guardian of the Estate or General Guardian, please attach documentation with the name, address and telephone number of the surety company holding your bond. 12. Have you ever been found liable in a subrogation action by an insurance or bonding agent? Yes_____ No_____ If yes, please attach a letter of explanation. 13. Have you ever been convicted or pleaded guilty or no contest to a misdemeanor or felony? 14. Have you ever been removed for cause as guardian or fiduciary? Yes _____
Yes___ No____
No ______
If yes, please attach a letter of explanation. 15. Have you ever been found civilly or criminally liable for an action of fraud, moral turpitude, misrepresentation, material omission, misappropriation, theft, or conversion? Yes _____ No _______ If yes, please explain._______________________________________________________________________ 16. Are you at least 21 years of age?
Yes______
17. Do you have special needs requiring NCGA attention?
No _______ Yes______
No _______
If yes, please explain. _______________________________________________________________________
I swear or affirm that the information provided in this application is true and correct to the best of my knowledge and belief. (Application must be signed before a Notary Public.) _________________________________ Signature of Applicant
_________________________________________________ Date
State of ______________________________________ County of ________________________________________ The foregoing instrument was acknowledged before me this ________ day of _________________________________ 20 ____, by __________________________________________ who is personally known to me or who has produced __________________________ as identification. _________________________ Notary Public
My Commission expires on ______________________________________
Return Application to: North Carolina Guardianship Association PO Box 17673 Raleigh, North Carolina 27619-7673 Phone 919-266-9204 Fax 919-266-9207 An Affiliate of the National Guardianship Association
